Ethos Release Form

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Medical Consent Form For Ethos School Year: May 2017 - April 2018 In the event of an emergency as determined by an employee of Ethos or an adult chaperone for Ethos Activities, I hereby give consent for my child to obtain any necessary emergency medical care, including but not limited to, medical, dental, or surgical treatment, which may include hospitalization, anesthesia, surgery or other emergent treatment. I understand that I will be financially responsible for all medical expenses incurred during the course of the provision of such medical care. ______________________________________________________________________________ Child’s Name Child’s Date of Birth

______________________________________________________________________________ Print –Parent(s)/Guardian(s) Name(s) Signature of Parent(s)/Guardian(s) Name(s)

______________________________________________________________________________ Home Phone # Work Phone #

______________________________________________________________________________ Parent/Guardian Cell Phone # Parent/Guardian Cell Phone #

____________________________________________________________________________ Emergency Contact Name, Relationship and Phone #

______________________________________________________________________________ Primary Physician’s Name, Address and Phone #

______________________________________________________________________________ Health Insurance Provider Policy/ID # Group #

Please list any allergies or medical conditions of which we should be aware: ________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________

Please list any current medications taken by the child: __________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Parental Waiver, Release of Liability, Indemnification and Consent Form for Ethos School Year: May 2017 - April 2018

As parent/guardian of minor ________________________, I hereby give my permission for my child/ward to attend and participate in the activities sponsored by Ethos Church. Furthermore, I fully assume the risk and agree to release and hold harmless Ethos Church, its Employees, Directors, Volunteers, Chaperones, or Agents, for any claims or demands related to bodily injury, loss, illness, death or disease incurred or caused by my child/ward, and for any loss or damage to any property of myself and my child/ward. I further agree to release, hold harmless, and indemnify Ethos Church, its Employees, Directors, Volunteers, Chaperones, or Agents, for any liability associated with the actions of my child/ward in connection with his or her participation in the activities sponsored by Ethos Church. I fully assume financial responsibility for any injury, loss, illness, death, disease or liability that may result from my child’s/ward’s participation in the activities sponsored by Ethos Church.

______________________________________________________________________________ Print Name of Child Participant Date ______________________________________________________________________________ Mother’s Signature Date ______________________________________________________________________________ Father’s Signature Date ______________________________________________________________________________ Custodial Parent’s Signature (if divorced) Date ______________________________________________________________________________ Legal Guardian’s Signature Date